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Updated: Jun 5 2021

Shoulder Arthrodesis

Images arthodesis.jpg
  • Introduction
    • The goal of shoulder arthrodesis is to provide a stable base for the upper extremity optimizing hand and elbow function
      • it remains an important treatment option in appropriately selected patients
    • Indications
      • stabilization of paralytic disorders
      • brachial plexus palsy
      • irreparable deltoid and rotator cuff deficiency with arthropathy
      • salvage of a failed total shoulder arthroplasty
      • reconstruction after tumor resection
      • painful ankylosis after chronic infection
      • recurrent shoulder instability which has failed previous repair attempts
      • paralytic disorders in infancy
    • Contraindications
      • ipsilateral elbow arthrodesis
      • contralateral shoulder arthrodesis
      • lack of functional scapulothoracic motion
      • trapezius, levator scapulae, or serratus anterior paralysis
      • Charcot arthropathy during acute inflammatory stage (Eichenholtz 0-2)
      • elderly patients
      • progressive neurologic disease
  • Anatomy
    • Glenohumeral articulation
      • a relatively small amount of surface area exists allowing for predictable fusion
      • to increase the available fusion area, decortication of both the glenohumeral articular surface and the articulation between the humeral head and the undersurface of the acromion is performed
      • only the glenoid fossa and base of the coracoid provide sufficient strength for fixation
  • Presentation
    • Symptoms
      • specific to the underlying condition necessitating arthrodesis
      • symptomatic dysfunction of the glenohumeral joint
  • Imaging
    • Radiographs
      • recommended views
        • AP, lateral, and axillary views to assess bone stock available for fusion and deformities
    • CT
      • better to evaluate glenoid bone loss especially in the setting of failed arthroplasty
  • Studies
    • EMG
      • indicated when the neurologic condition of the scapular muscles is ill-defined
  • Surgical Technique
    • Approach
      • S-shaped skin incision beginning over the scapular spine, traversing anteriorly over the acromion, and extending down the anterolateral aspect of the arm
    • Fusion position
      • goal is to allow patients to reach their mouths for feeding
        • think "30°-30°-30°"
          • 20°-30° of abduction
          • 20°-30° of forward flexion
          • 20°-30° of internal rotation
    • Technique
      • rotator cuff is resected from the proximal humerus and the biceps tendon is tenodesed
      • glenoid and humeral head articular surfaces and the undersurface of the acromion are decorticated
      • arm is placed into the position of fusion (30°-30°-30°)
      • a 10-hole, 4.5 mm pelvic reconstruction plate is contoured along the spine of the scapula, over the acromion, and down the shaft of the humerus
      • compression screws are placed through the plate across the glenohumeral articular surface into the glenoid fossa
      • the plate is anchored to the scapular spine with a screw into the base of the coracoid
    • Postoperative care
      • a thermoplastic orthosis is applied the day after surgery and is maintained for 6 weeks
      • at 6 weeks, may transition to a sling if there are no radiographic signs of loosening
      • at 3 months, mobilization exercises and thoracoscapular strengthening are commenced if no radiographic signs of loosening are present
      • expected recovery period is 6-12 months
  • Complications
    • Infection
    • Nonunion
    • Malposition
    • Prominent hardware
    • Humeral shaft fracture
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